SENATE PUBLIC AFFAIRS COMMITTEE SUBSTITUTE FOR
SENATE BILL 782
47th legislature - STATE OF NEW MEXICO - first session, 2005
AN ACT
RELATING TO HEALTH; ENACTING THE STATE COVERAGE INITIATIVE ACT; AUTHORIZING A HEALTH INSURANCE PLAN FOR UNINSURED ADULTS PURSUANT TO A MEDICAID WAIVER; ALLOWING ENROLLMENT THROUGH SMALL BUSINESSES; ESTABLISHING COST-SHARING REQUIREMENTS; PROVIDING FOR ENROLLMENT BY THE SELF-EMPLOYED; REQUIRING ADOPTION OF REGULATIONS; MAKING AN APPROPRIATION.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
Section 1. SHORT TITLE.--This act may be cited as the "State Coverage Initiative Act".
Section 2. DEFINITIONS.--As used in the State Coverage Initiative Act:
A. "department" means the human services department;
B. "eligible employee" means an individual who is eligible to be covered under the health plan through a participating small business;
C. "health plan" means a health insurance plan for uninsured individuals created by the department under a medicaid waiver program as authorized by the State Coverage Initiative Act;
D. "individual" means an adult natural person, nineteen to sixty-five years of age, including an eligible employee; and
E. "participating small business" means a business fulfilling the requirements of Section 6 of the State Coverage Initiative Act that offers the health plan to its eligible employees.
Section 3. HEALTH PLAN FOR UNINSURED INDIVIDUALS--MEDICAID WAIVER--AUTHORIZATION.--Provided that benefits and eligibility criteria for other medicaid beneficiaries and programs are not reduced, and subject to available funding, the department is authorized to implement a medicaid waiver program to provide a health plan for uninsured individuals.
Section 4. COVERAGE AND BENEFITS.--The department shall prescribe by rules the coverage and benefits to be offered under the health plan, provided that the coverage and benefits shall be generally comparable to the most common commercial group health plans provided in the state. If the department provides the health plan through a health maintenance organization or similar managed care organization, the plan shall include coverage and benefits as specified in the Health Maintenance Organization Law. The health plan shall not exclude pre-existing health conditions.
Section 5. ELIGIBILITY.--Subject to limits on the total number of individuals authorized to be served, as established in the medicaid waiver granted by the federal government, and the availability of funds, an individual shall be eligible to participate in the health plan if the individual:
A. has family income up to two hundred percent of the federal poverty level after applicable deductions and disregards, or a higher income level as may be established by the department by rule;
B. has not had other health insurance for at least six months, unless the individual was involuntarily terminated from that other health insurance coverage;
C. pays the monthly individual premium share established by the department, based on the individual's income level, unless the premium share is waived or is paid on the individual's behalf as provided in Sections 7, 8 and 10 of the State Coverage Initiative Act; and
D. is employed by a participating small business or enrolls in the health plan directly pursuant to Section 9 of the State Coverage Initiative Act.
Section 6. ENROLLMENT THROUGH SMALL BUSINESSES.--A small business may offer the health plan to its eligible employees, and the department may market the plan through that business, if the business:
A. is licensed to do business in this state;
B. employs fifty or fewer employees in the state, whether full time or part time;
C. has not dropped or stopped offering group health insurance for its employees within the past twelve months;
D. agrees to abide by the department rules promulgated for the health plan; and
E. pays the monthly individual premium share established by the department for each eligible employee who enrolls in the health plan, unless the premium share is waived or is paid on the individual's behalf as provided in Sections 7, 8 and 10 of the State Coverage Initiative Act.
Section 7. COST-SHARING--INDIVIDUALS.--
A. The department shall adopt a schedule setting the amount of an individual's monthly premium share for participation in the health plan based on a sliding income scale; provided that an individual with a family income that does not exceed the federal poverty level, or a higher income level as may be established by the department by rule, shall not be required to pay a monthly premium share.
B. The department shall adopt a schedule setting the amount of an individual's copayments for covered benefits in the health plan based on a sliding income scale; provided that copayments for an individual with a family income that does not exceed the federal poverty level may be waived by the department and in any event shall not exceed a nominal amount pursuant to Title 19 of the federal Social Security Act. Copayments under the health plan shall not exceed copayments established for other medicaid beneficiaries at comparable income levels for comparable medicaid coverage and benefits as provided in the state medicaid plan required by Titles 19 and 21 of the federal Social Security Act.
C. The maximum annual cost of premium shares and copayments for an individual participating in the plan shall not exceed annual cost-sharing limits established for other medicaid beneficiaries at comparable income levels for comparable coverage and benefits. In no event shall an individual's annual cost exceed five percent of family income. Once an individual's cost-sharing expenses equal or exceed the established limit, the department shall waive further premium shares or copayments that would otherwise be due for the balance of the year.
Section 8. SMALL BUSINESS PREMIUM SHARE.--The department shall establish the amount of a participating small business's monthly premium share for each eligible employee who participates in the health plan.
Section 9. DIRECT ENROLLMENT IN LIEU OF PARTICIPATING SMALL BUSINESS.--An individual who is otherwise eligible to enroll in the health plan, but who is not employed by a participating small business, shall be considered self-employed for the purposes of the plan and may enroll in the plan directly. In order to enroll and participate directly in the health plan, an individual shall pay the individual premium share based on the individual's income level, as established in Section 7 of the State Coverage Initiative Act, as well as the equivalent of a small business's monthly premium share, as established in Section 8 of the State Coverage Initiative Act; provided that the department shall waive the equivalent of the small business's share for an individual with a family income that does not exceed the federal poverty level, or a higher income level as may be established by the department by rule.
Section 10. LOCAL GOVERNMENT PAYERS AUTHORIZED--FUNDS TO BE MATCHED.--The premium shares established for an individual or small business or both pursuant to Sections 7, 8 and 9 of the State Coverage Initiative Act may be paid to the department by voluntary transfer of county funds, transfer of other state funds or donations. The department shall use money received from interagency and intergovernmental transfers and donations for purposes of matching requirements under Title 19 or Title 21 of the federal Social Security Act.
Section 11. COSTS--DEPARTMENT AND FEDERAL GOVERNMENT.--The costs of providing the health plan not met by payments of premium shares from individuals participating in the health plan, participating small businesses or other entities pursuant to Section 10 of the State Coverage Initiative Act shall be met by the department pursuant to matching requirements under Title 19 or Title 21 of the federal Social Security Act.
Section 12. RULES.--The department shall promulgate rules for operation of the health plan, consistent with the provisions of the State Coverage Initiative Act.
Section 13. APPROPRIATION.--Four million dollars ($4,000,000) is appropriated from the general fund to the human services department for expenditure in fiscal year 2006 to provide a health insurance plan for uninsured adults, including employees of small businesses, through a medicaid waiver program pursuant to the State Coverage Initiative Act. Any unexpended or unencumbered balance remaining at the end of fiscal year 2006 shall revert to the general fund.
Section 14. EFFECTIVE DATE.--The effective date of the provisions of this act is July 1, 2005.
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